Evaluation and Management

of Neck Masses in Children

JEREMY D. MEIER, MD, and JOHANNES FREDRIK GRIMMER, MD
University of Utah School of Medicine, Salt Lake City, Utah

Neck masses in children usually fall into one of three categories: developmental, inflammatory/reactive, or neoplastic.
Common congenital developmental masses in the neck include thyroglossal duct cysts, branchial cleft cysts, dermoid
cysts, vascular malformations, and hemangiomas. Inflammatory neck masses can be the result of reactive lymphade-
nopathy, infectious lymphadenitis (viral, staphylococcal, and mycobacterial infections; cat-scratch disease), or Kawa-
saki disease. Common benign neoplastic lesions include pilomatrixomas, lipomas, fibromas, neurofibromas, and
salivary gland tumors. Although rare in children, malignant lesions occurring in the neck include lymphoma, rhab-
domyosarcoma, thyroid carcinoma, and metastatic nasopharyngeal carcinoma. Workup for a neck mass may include
a complete blood count; purified protein derivative test for tuberculosis; and measurement of titers for Epstein-Barr
virus, cat-scratch disease, cytomegalovirus, human immunodeficiency virus, and toxoplasmosis if the history raises
suspicion for any of these conditions. Ultrasonography is the preferred imaging study for a developmental or palpable
mass. Computed tomography with intravenous contrast media is recommended for evaluating a malignancy or a sus-
pected retropharyngeal or deep neck abscess. Congenital neck masses are excised to prevent potential growth and sec-
ondary infection of the lesion. Antibiotic therapy for suspected bacterial lymphadenitis should target Staphylococcus
aureus and group A streptococcus. Lack of response to initial antibiotics should prompt consideration of intravenous
antibiotic therapy, referral for possible incision and drainage, or further workup. If malignancy is suspected (accom-
panying type B symptoms; hard, firm, or rubbery consistency; fixed mass; supraclavicular mass; lymph node larger
than 2 cm in diameter; persistent enlargement for more than two weeks; no decrease in size after four to six weeks;
absence of inflammation; ulceration; failure to respond to antibiotic therapy; or a thyroid mass), the patient should
be referred to a head and neck surgeon for urgent evaluation and possible biopsy. (Am Fam Physician. 2014;89(5):353-
358. Copyright © 2014 American Academy of Family Physicians.)

P
CME This clinical content
conforms to AAFP criteria
for continuing medical
education (CME). See
CME Quiz Questions on
page 327.
Author disclosure: No rel-
evant financial affiliations.
rimary care physicians commonly
see children with a neck mass.
These masses often cause signifi-
cant alarm and anxiety to the care-
giver; however, a neck mass in a child is
seldom malignant.1 In a review of children
with neck masses that were biopsied in a ter-
tiary referral center, 11% were cancerous.2 It
is likely that the malignancy rate would be
much lower in a primary care physician’s
office. In one series, 44% of children younger
than five years had palpable lymph nodes,
suggesting that benign lymphadenopathy is
common in this population.3 Recognizing
the possibilities within a broad differential
diagnosis will allow the experienced phy-
sician to effectively evaluate and identify
these lesions. Understanding the appropriate
workup and indications for intervention will
prevent use of unnecessary diagnostic tests
and therapies.
History and Physical Examination
Neck masses in children typically fall
into one of three categories: developmen-
tal, inflammatory/reactive, or neoplastic
(Table 1). Important aspects of the history
and physical examination can help narrow
the differential diagnosis into one of these
categories (Table 2).
TIMING
The onset and duration of symptoms should
be elicited during the initial history. A mass
present since birth or discovered during
the neonatal period is usually benign and
developmental. Vascular malformations
present at birth and grow with the child,
whereas hemangiomas develop a few weeks
after birth and have a rapid growth phase.
Developmental masses may present later
in life, either with superimposed infection
or with growth over time. A new, rapidly

March 1, 2014
Downloaded Volume
from◆ the 89, Family
American Number 5 website at www.aafp.org/afp.
Physician www.aafp.org/afp  American Academy of Family
Copyright © 2013 American Family
Physicians. For thePhysician  353
private, noncom-
mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
Neck Masses
Table 1. Differential Diagnosis of Neck Masses in Children

Diagnosis

Location Developmental Inflammatory/reactive Neoplastic

Anterior Branchial cleft cyst,* Reactive lymphadenopathy,* lymphadenitis (viral, Lymphoma

sternocleidomastoid vascular malformation bacterial),* sternocleidomastoid tumor of infancy

Midline Thyroglossal duct cyst,* — Thyroid tumor

dermoid cyst*

Occipital Vascular malformation Reactive lymphadenopathy,* lymphadenitis* Metastatic lesion

Preauricular Hemangioma, vascular Reactive lymphadenopathy,* lymphadenitis,* Pilomatrixoma, salivary

malformation, type I parotitis,* atypical mycobacterium gland tumor
branchial cleft cyst

Submandibular Branchial cleft cyst,* Reactive lymphadenopathy,* lymphadenitis,* Salivary gland tumor
vascular malformation atypical mycobacterium

Submental Thyroglossal duct cyst,* Reactive lymphadenopathy,* lymphadenitis (viral, —

dermoid cyst* bacterial)*

Supraclavicular Vascular malformation — Lymphoma,*

metastatic lesion

*—Type of lesions that are more commonly found in that location.

growing mass is usually inflammatory. If the mass per-
sists for six weeks, or enlarges after initial antibiotic
therapy, a neoplastic lesion must be considered. Concern
for airway involvement or malignancy should prompt
immediate referral or imaging. A slowly enlarging mass
over months to years suggests benign lesions such as
lipomas, fibromas, or neurofibromas.
ASSOCIATED SYMPTOMS
Fevers, rapid enlargement or tenderness of the mass,
or overlying erythema indicates a likely inflammatory
etiology (Figure 1). Most malignant neck masses in chil-
dren are asymptomatic and are not painful.4 However,
acute infection in a necrotic, malignant lymph node can
also occur. An upper respiratory tract infection preceding
the onset of the mass suggests possible reactive lymph-
adenopathy or a secondary infection of a congenital cyst.
Constitutional type B symptoms such as fever, malaise,
weight loss, and night sweats suggest a possible malig-
nancy. Lymphadenopathy with high fever, bilateral con-
junctivitis, and oral mucosal changes with a strawberry
tongue likely represents Kawasaki disease.

RECENT EXPOSURES
Table 2. History and Physical Examination Recent upper respiratory tract infections; animal expo-
Clues to Diagnosis in Children sures (cat scratch, cat feces, or wild animals); tick bites;
with a Neck Mass
contact with sick children; contact with persons who
have tuberculosis; foreign travel; and exposure to ion-
Finding Diagnosis
izing radiation should be reviewed.5 Medications should
History also be reviewed because drugs such as phenytoin (Dilan-
Fevers, pain Inflammatory tin) can cause pseudolymphoma or can cause lymphade-
Present at birth Developmental nopathy associated with anticonvulsant hypersensitivity
Rapidly growing mass Inflammatory, malignancy syndrome.
Physical examination
LOCATION
Hard, irregular, firm, immobile Malignancy
Larger than 2 cm Malignancy The location of the neck mass provides many clues to the
Midline location Thyroglossal duct cyst, diagnosis. The most common midline cystic neck masses
dermoid cyst, thyroid mass are thyroglossal duct cysts and dermoid cysts (Figure 2).
Shotty lymphadenopathy Reactive lymph nodes Thyroglossal duct cysts are often located over the hyoid
Supraclavicular location Malignancy bone and elevate with tongue protrusion or swallowing,
whereas dermoid cysts typically move with the overlying

354  American Family Physician www.aafp.org/afp Volume 89, Number 5 ◆ March 1, 2014
 Neck Masses

skin.6 Malignant anterior neck masses are

usually caused by thyroid cancer. Congeni-
tal masses in the lateral neck include bran-
chial cleft anomalies, vascular or lymphatic
malformations, and fibromatosis colli.
Lymphadenopathy in the lateral neck can be
inflammatory or neoplastic. Supraclavicular
A B
lymph nodes or those in the posterior tri-
angle (behind or lateral to the sternocleido- Figure 1. (A) Lateral neck mass in a seven-month-old girl. She presented
mastoid muscle) have a higher incidence of with fever, swelling for three days, overlying erythema, tenderness,
malignancy than lymph nodes in the ante- and an elevated white blood cell count. (B) Computed tomography
with contrast media showed a cystic mass (arrow) with enhancing rim
rior triangle (anterior or medial to the ster- suggestive of suppurative lymphadenitis. The abscess was incised and
nocleidomastoid muscle).2 Generalized or drained, and was found to be positive for Staphylococcus aureus.
multiple anatomic sites of lymphadenopathy
increase the chance of malignancy.7,8

PALPATION

The consistency of the mass provides useful

information. Shotty lymphadenopathy refers
to the presence of multiple small lymph
nodes that feel like buckshot under the skin.9
In the neck, this usually implies a reactive
lymphadenopathy from an upper respira-
tory tract infection. A hard, irregular mass,
or a firm or rubbery mass that is immobile
or fixed to the deep tissues of the neck may
indicate malignancy. Figure 2. Midline neck mass in a four-year-old boy consistent with a
thyroglossal duct cyst.
SIZE

Size alone cannot confirm or exclude a diag-

nosis. However, cervical lymph nodes up to
1 cm in size are normal in children younger
than 12 years,10 with the exception of the
jugulodigastric lymph node, which can be
as large as 1.5 cm. Persistent enlarged lymph
nodes greater than 2 cm that do not respond
to empiric antibiotic therapy should be eval-
uated for possible biopsy.
Initial Diagnostic Testing
The primary care physician ultimately must
determine whether further invasive workup
or treatment is necessary, or if watchful wait-
ing is appropriate. Laboratory studies may be
indicated if there is concern about a systemic
disease or to confirm a diagnosis suspected
from the history and physical examination.
Ordering routine studies in a shotgun style
approach is rarely indicated and seldom
can reliably rule in or out a specific dis-
ease (Table 3). Results of a complete blood
Table 3. Indications for Ordering Clinical Laboratory or
Imaging Studies in the Workup of a Child with a Neck Mass
Test
Bartonella henselae titers
Complete blood count
Computed tomography
Magnetic resonance imaging
Purified protein derivative (PPD)
test for tuberculosis
Ultrasonography
Viral titers
(cytomegalovirus, Epstein-
Barr virus, human immuno­
deficiency virus, toxoplasmosis)
Indication
Recent exposure to cats
Serious systemic disease suspected
(e.g., leukemia, mononucleosis)
Imaging study for retropharyngeal
or deep neck abscess, or suspected
malignancy
Preferred if vascular malformation is
suspected
Exposure to tuberculosis, young child in
rural community (atypical tuberculosis)
Recommended initial imaging study
for a developmental mass, palpable
mass, or suspected thyroid problem
If history suggests exposure or a
suspected inflammatory mass is not
responding to antibiotics

March 1, 2014 ◆ Volume 89, Number 5 www.aafp.org/afp American Family Physician 355

Neck Masses
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
When indicated, ultrasonography is the preferred initial imaging study
for most children with a neck mass.
Empiric antibiotic therapy with observation for four weeks is acceptable
for children with presumed reactive lymphadenopathy.
Excision of presumed congenital neck masses in children is recommended
to confirm the diagnosis and to prevent future problems.
In children, enlarged lymph nodes that are rubbery, firm, immobile, or
that persist for longer than six weeks or that enlarge during a course
of antibiotics should be considered for biopsy.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.
count with differential may be abnormal with infectious
lymphadenitis. A complete blood count with differential
is recommended in patients with a history and physi-
cal examination suggestive of infection or malignancy;
however, good evidence to support the value of routine
complete blood count is lacking. Atypical lymphocyto-
sis can occur in mononucleosis, and pancytopenia with
blast cells suggests leukemia.11 If there was recent expo-
sure to cats, measurement of Bartonella henselae titers
to evaluate for cat-scratch disease should be considered.
Measurement of titers for Epstein-Barr virus, cytomega-
lovirus, human immunodeficiency virus, and toxoplas-
mosis also should be considered if the history suggests
possible exposure or if a presumed inflammatory mass is
not responding to antibiotics.
Imaging may help with diagnosis and with planning
for invasive intervention. The American College of Radi-
ology considers ultrasonography, computed tomogra-
phy with intravenous contrast media, and magnetic
resonance imaging with or without intravenous con-
trast media appropriate imaging studies for a child up to
14 years of age presenting with a neck mass.12 Ultrasonog-
raphy is the preferred initial imaging study in an afebrile
child with a neck mass or a febrile child with a palpa-
ble neck mass.12 Ultrasonography is a relatively quick,
inexpensive imaging modality that avoids radiation
and helps define the size, consistency (solid vs. cystic),
shape, vascularity, and location of the mass. Malignancy
is more likely with an abnormally shaped lymph node
compared with a lymph node that retains its normal
architecture. If fine-needle aspiration is warranted for
deep neck masses, ultrasonographic guidance can help.
Ultrasonography should be performed when a thyro-
glossal duct cyst is suspected to determine the presence
356  American Family Physician www.aafp.org/afp Volume 89, Number 5
Evidence
rating References Comments
C 12 Based on expert opinion
C 11 Based on a consensus-
based practice guideline
C 1 Based on observational
studies
C 19, 20 From a consensus
guideline based on
observational studies
of a normal thyroid gland. Ultrasonography also should
be the initial imaging study for the evaluation of a thy-
roid mass.
Computed tomography with intravenous contrast
media is the preferred study for evaluating a malignancy
or a suspected retropharyngeal or deep neck abscess that
may require surgical drainage.12 Computed tomography
with contrast media should not be ordered for a thyroid
mass; uptake of contrast media by thyroid tissue could
delay subsequent radioactive iodine treatment if needed.
Magnetic resonance imaging better defines soft tissue
anatomy 13 and avoids the radiation exposure from com-
puted tomography. However, the expense and frequent
need for sedation often limit magnetic resonance imag-
ing as the initial imaging study of choice. Magnetic res-
onance imaging is the imaging study of choice when a
vascular malformation is suspected.
Fine-needle aspiration may provide critical diagnostic
information and avoid the need for open biopsy. Sensitiv-
ity of fine-needle aspiration in children is usually greater
than 90%14-16 and specificity is approximately 85%.16
However, in one series, 76% of the children required
general anesthesia; a cytopathologist who has experience
with neck lesions in children is essential.16 Occasionally,
fine-needle aspiration does not provide sufficient tissue
or adequate evaluation of lymph node architecture, and
an open biopsy is needed to determine the diagnosis.
Initial Treatment and Referral
Little evidence exists to definitively determine the best
approach for the child with a neck mass. Current sug-
gested algorithms are based on expert opinion.17 Obser-
vation is recommended initially in children with cervical
lymphadenitis that is bilateral, whose lymph nodes are
◆ March 1, 2014
 Neck Masses

smaller than 3 cm and are not erythematous or exqui-

sitely tender.18 An empiric course of antibiotics should
be considered for patients with cervical lymphadenitis if
they have systemic symptoms (e.g., fever, chills), unilat-
eral lymphadenopathy, or erythema and tenderness, or
if their lymph nodes are larger than 2 to 3 cm.18 If an
antibiotic is prescribed, a 10-day course of oral cepha-
lexin (Keflex), amoxicillin/clavulanate (Augmentin), or
clindamycin is recommended based on expert opinion,
because the most common organisms are Staphylococcus
aureus and group A streptococcus.11 Empiric antibiotic
therapy with observation for four weeks is acceptable
for presumed reactive lymphadenopathy.11 Figure 3 is an
algorithm for the treatment of a child presenting with a
neck mass.
Children with congenital neck masses should be
referred to a specialist to consider definitive exci-
sion (Table 4). Excision is recommended to confirm
the diagnosis and to prevent future problems (e.g.,
potential growth, secondary infection).1 Patients with
Table 4. Indications for Referral in Children
with a Neck Mass
Developmental mass requiring excision for definitive therapy
Infectious lymphadenitis requiring incision and drainage
Mass suggests malignancy
Enlarged lymph node persistent for six weeks
Firm, rubbery lymph node > 2 cm in diameter
Hard, immobile mass
Size increasing during antibiotic therapy
Supraclavicular mass
Thyroid mass
suppurative lymphadenitis or a neck abscess that does
not respond to oral antibiotic therapy should be referred
for intravenous antibiotics, possible incision and drain-
age, or further workup. If malignancy is suspected
(accompanying type B symptoms; hard, firm, or rubbery

Treatment of Children with Neck Masses

Child presents with a neck mass

Signs of infection (e.g., erythema,

fevers, chills, tenderness)?

Yes No

Consider trial of Suspicious for malignancy (e.g., initial size

oral antibiotics greater than 3 cm; hard, firm, immobile mass;
associated type B symptoms; thyroid mass)?

Improvement in
two to three days? Yes No

Urgent referral to head Developmental mass suspected

and neck surgeon (e.g., thyroglossal duct or dermoid
Yes No
cyst, vascular malformation)?
Complete 10-day Order imaging
course of antibiotics (e.g., ultrasonography)
Yes No

Abscess seen on imaging? Referral to a head Observation for

and neck surgeon four to six weeks

Yes
Consultation for
surgical drainage
No
Consider intravenous antibiotics,
consultation with infectious disease
or ear, nose, and throat specialist
Consider referral to head and neck surgeon
if the mass enlarges during observation or
if an asymptomatic mass larger than 2 cm
persists longer than four to six weeks

Figure 3. Algorithm for the treatment of children with neck masses.

March 1, 2014 ◆ Volume 89, Number 5 www.aafp.org/afp American Family Physician 357

Neck Masses
consistency; fixed mass; supraclavicular mass; lymph
node larger than 2 cm in diameter; persistent enlarge-
ment for more than two weeks; no decrease in size after
four to six weeks; absence of inflammation; ulceration;
failure to respond to antibiotic therapy; or a thyroid
mass), the patient should be referred to a head and
neck surgeon for urgent evaluation and possible biopsy.
Although rare, malignant lesions such as lymphoma,
rhabdomyosarcoma, thyroid carcinoma, and metastatic
nasopharyngeal carcinoma can occur in children.
An asymptomatic lesion that appears to be an enlarged
lymph node creates a difficult dilemma for the primary
care physician. Usually, the patient or caregiver is anx-
ious for a diagnosis and an intervention. Most cases
of lymphadenopathy are self-limited and require only
observation and patience.11 Enlarged lymph nodes that
are rubbery, firm, immobile, or that persist for longer
than six weeks or enlarge during a course of antibiotics
should be evaluated by a head and neck surgeon, and a
biopsy is recommended.19-21
Data Sources: A PubMed search was completed in Clinical Queries using
the key term pediatric neck mass. The search included systematic reviews,
meta-analyses, consensus development conferences, and guidelines. Also
searched was the Cochrane database. Search dates: August 25, 2011, and
December 2, 2013.
The Authors
JEREMY D. MEIER, MD, is an assistant professor in the Division of Otolar-
yngology at the University of Utah School of Medicine in Salt Lake City.
JOHANNES FREDRIK GRIMMER, MD, is an associate professor in the Divi-
sion of Otolaryngology at the University of Utah School of Medicine.
Address correspondence to Jeremy D. Meier, MD, University of Utah,
50 N. Medical Dr., Rm 3C120 SOM, Salt Lake City, UT 84132 (e-mail:
Jeremy.meier@imail.org). Reprints are not available from the authors.
REFERENCES
1. Connolly AA, MacKenzie K. Paediatric neck masses—a diagnostic
dilemma. J Laryngol Otol. 1997;111(6):541-545.
358  American Family Physician www.aafp.org/afp Volume 89, Number 5
2. Torsiglieri AJ Jr, Tom LW, Ross AJ III, Wetmore RF, Handler SD, Potsic WP.
Pediatric neck masses: guidelines for evaluation. Int J Pediatr Otorhino-
laryngol. 1988;16(3):199-210.
3. Herzog LW. Prevalence of lymphadenopathy of the head and neck in
infants and children. Clin Pediatr (Phila). 1983;22(7):485-487.
4. Cunningham MJ, Myers EN, Bluestone CD. Malignant tumors of the
head and neck in children: a twenty-year review. Int J Pediatr Otorhino-
laryngol. 1987;13(3):279-292.
5. Bauer PW, Lusk RP. Neck masses. In: Bluestone CD, Stool SE, Alper CM,
et al., eds. Pediatric Otolaryngology. 4th ed. Philadelphia, Pa.: Saunders;
2003:1629-1647.
6. Acierno SP, Waldhausen JH. Congenital cervical cysts, sinuses and fistu-
lae. Otolaryngol Clin North Am. 2007;40(1):161-176, vii-viii.
7. Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood
peripheral lymphadenopathy. J Pediatr Surg. 1999;34(10):1447-1452.
8. Yaris N, Cakir M, Sözen E, Cobanoglu U. Analysis of children with
peripheral lymphadenopathy. Clin Pediatr (Phila). 2006;45(6):544-549.
9. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am
Fam Physician. 1998;58(6):1313-1320.
10. Park YW. Evaluation of neck masses in children. Am Fam Physician.
1995;51(8):1904-1912.
11. Leung AK, Robson WL. Childhood cervical lymphadenopathy. J Pediatr
Health Care. 2004;18(1):3-7.
12. American College of Radiology. ACR Appropriateness Criteria. Neck mass/
adenopathy. http://www.acr.org/~/media/ACR/Documents/AppCriteria/
Diagnostic/NeckMassAdenopathy.pdf. Accessed December 2, 2013.
13. Turkington JR, Paterson A, Sweeney LE, Thornbury GD. Neck masses in
children. Br J Radiol. 2005;78(925):75-85.
14. Ramadan HH, Wax MK, Boyd CB. Fine-needle aspiration of head and
neck masses in children. Am J Otolaryngol. 1997;18(6):400-404.
15. Mobley DL, Wakely PE Jr, Frable MA. Fine-needle aspiration biopsy:
application to pediatric head and neck masses. Laryngoscope. 1991;101
(5):469-472.
16. Anne S, Teot LA, Mandell DL. Fine needle aspiration biopsy: role in diag-
nosis of pediatric head and neck masses. Int J Pediatr Otorhinolaryngol.
2008;72(10):1547-1553.
17. Dulin MF, Kennard TP, Leach L, Williams R. Management of cervical
lymphadenitis in children. Am Fam Physician. 2008;78(9):1097-1098.
18. Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric
Infectious Diseases. 2nd ed. New York, NY: Churchill Livingstone; 2003.
19. Dickson PV, Davidoff AM. Malignant neoplasms of the head and neck.
Semin Pediatr Surg. 2006;15(2):92-98.
20. Citak EC, Koku N, Demirci M, Tanyeri B, Deniz H. A retrospective chart
review of evaluation of the cervical lymphadenopathies in children.
Auris Nasus Larynx. 2011;38(5):618-621.
21. Umapathy N, De R, Donaldson I. Cervical lymphadenopathy in children.
Hosp Med. 2003;64(2):104-107.
◆ March 1, 2014